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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> r <br /> JOB ADDRESS: PERMIT WP #: <br /> LENSED CONT�RACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> Contractor Name: <br /> License #: Expiration Date: 41 �� 21 <br /> Signature: i( Title: ( ' <br /> Print Name: Y ` Date: Z`�C <br /> WORKERS' Com;ENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> ❑ provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compen§ation F' urance carrier and policy numbers are: <br /> Carrier: i- ��: � Policy #: / � _� —1 ,� Exp. Date: L� 2) <br /> I certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation law of California. and agree that if I <br /> should become subject to workers'compensation prov}sions of Section 3700 of the Labor Code. I shall <br /> firth 'ith comply with those provisions. <br /> Signature: <br /> Print Name: ~ �� <br /> WARNING: FAILURE TO SECURE WORKERSCO NSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> " I r / ,. LA <br /> rI, l ( Il,' hereby authorise G <br /> fume of CST License 4uthonzed Representative t Name of Authorized Ad6flt <br /> to sign this San Joaquin Cou Well $ oring Permit Application on my behalf. I understand this <br /> authorization is valid for one ye and is A`17 <br /> dto twoWklan dated o the font page of this application. <br /> "h <br /> Si§natum of C-67 Ucon=Representative <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />